Is POS Insurance Right for You?

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Point-of-service (POS) insurance is a type of managed care health insurance plan that allows policyholders to get coverage for in-network and out-of-network providers. This offers POS members greater flexibility with where they can seek medical care. However, POS plans typically require policyholders to elect a primary care physician (PCP) and obtain a referral before seeing a specialist.

Learn more about the benefits and drawbacks of POS insurance and if it’s right for you.

How Does POS Insurance Work?

POS is a type of health insurance plan that allows policyholders to get medical care from in-network providers, as well as out-of-network providers. POS health insurance plans typically offer more flexibility than other types of managed care plans, such as HMOs (health maintenance organizations), which require policyholders to receive care from specific providers.

POS Rules for Subscribers

POS health insurance plans have certain rules that policyholders must follow in order to receive coverage. Here are some common POS rules that subscribers may be required to follow:

  1. Choose a PCP: Typically, subscribers must select a PCP from a list of in-network providers. The PCP serves as the subscriber's main point of contact for healthcare issues and, when necessary, coordinates care with additional healthcare professionals or specialists.
  2. Get referrals for specialists: Referrals from the PCP are required before a member can see a specialist or receive certain types of medical services.
  3. Use in-network providers: Subscribers typically receive the most coverage and the lowest out-of-pocket costs when they use an in-network provider. Out-of-pocket costs increase when seeing an out-of-network provider.
  4. Pay copays and coinsurance: Subscribers may be required to pay a copay or coinsurance for each medical visit or service they receive. The copay or coinsurance amount will depend on the terms of the policy and the type of service being received.
  5. Meet deductibles: Subscribers may have to pay a certain amount out-of-pocket before their insurance company begins paying for covered expenses if the PCP is outside of the plan’s network.
  6. Meet out-of-pocket maximums: Subscribers may have an annual or lifetime maximum on the amount they have to pay out of pocket for covered expenses. Once the out-of-pocket maximum has been met, the insurance company will typically pay for all covered expenses for the remainder of the policy year.

Primary Care Physician

Members of POS plans must have a PCP in order to see a specialist.

To see a specialist, POS members must visit their PCP and obtain a referral that authorizes them to schedule an appointment.

While it may seem more time-consuming than scheduling a visit with a specialist directly, having a long-term PCP can be quite advantageous to your health. A PCP will become familiar with your medical history and make more informed decisions about your treatment.

Is POS Insurance Right for Me?

POS plans have several attractive features — receiving some coverage for out-of-network is definitely a huge plus. However, POS plans do require referrals for specialist visits, which can be inconvenient for some consumers.

Pros

Cons

Reduced medical expenses

PCP requirement

Specialist coverage

Referrals

No paperwork for in-network

 

Pros

  • Reduced medical expenses: When you receive care from an in-network provider, your out-of-pocket expenses will be smaller.
  • Specialist coverage: You are still covered if you see a specialist outside your approved network.
  • No paperwork for in-network coverage: The paperwork is typically handled for you when you receive treatment and services that are in-network.

Cons

  • PCP requirement: You are required to have a primary care physician with a POS, unlike other types of health plans.
  • Referrals: Depending on your plan, you might need a referral from your primary care physician (PCP) to see an in-network specialist.

How Much Does POS Insurance Cost?

Since coverage can extend to out-of-network providers, the cost of a POS plan is typically higher than other plan types. The exact cost will vary from person to person and be affected by a number of variables, including:

  • Age
  • Deductible
  • Health history
  • Health plan
  • State

POS insurance is offered in five tiers: bronze, silver, gold, platinum and catastrophic. Depending on the tier you select, your insurance premium will change. Health plans in the bronze tier will have the lowest monthly payments and the higher out-of-pocket expenses, whereas those in the platinum tier have some of the highest monthly premiums but significantly reduced out-of-pocket expenses. The quality of care being provided is not affected by these tiers.

Find an Affordable POS Insurance Plan

How To Get POS Insurance

There are several ways to get a POS plan:

  1. Employer-sponsored health insurance: Many employers offer their employees a range of coverage options, including POS plans. If you are employed, you can ask your employer about their health insurance options and enroll in a POS plan if available.
  2. Individual health insurance: If you are self-employed or do not have access to employer-sponsored health insurance, you can purchase a POS plan directly from an insurance company or through a broker or insurance agent.
  3. Government-sponsored health insurance: If you meet certain eligibility requirements, you may be able to get POS health insurance through a government-sponsored program, such as Medicaid or the Children's Health Insurance Program (CHIP).
  4. Health insurance marketplace: If you are not eligible for employer-sponsored health insurance or a government-sponsored program and do not have access to an individual health insurance policy, you can shop for a POS plan through the health insurance marketplace.

Enrolling in a POS health insurance policy typically requires you to complete an application and provide information about your health history, income and other personal details. The insurance company will review the application and determine whether to accept you for coverage and at what rate. It's a good idea to shop around and compare quotes from different insurance companies to find the best POS plan for your needs and budget.

What's the Difference Between POS, HMO, PPO and EPO?

A POS is one of several coverage options available by health insurance companies. Each coverage type dictates how coverage works with in- and out-of-network providers, if you must elect a PCP or obtain a referral for a specialist. Below, we compare POS plans to HMOs (health maintenance organization), PPOs (preferred provider organization) and EPO's (exclusive provider organization).

 

HMO

PPO

EPO

POS

Primary Care Physician Required?

Yes

No

No

Yes

Referral Required for Specialists?

Yes

No

No

Yes

Out-of-Network Coverage?

No

Yes

No

Yes

Network Size

Lowest

Highest

Lower

Higher

Cost

Lowest cost

Highest cost

Lower cost

Higher Cost

The table below shows the difference in deductibles for each insurance type.

deductible costs by health insurance plan type in line graph

Note: Deductibles may not apply when visiting an in-network PCP.

POS vs. HMO

Both HMOs and POS plans require users to get referrals before seeing a specialist. Having an HMO, however, your insurer only covers you for in-network medical care unless it’s an emergency. A POS, on the other hand, allows users to receive coverage for out-of-network medical services.

POS vs. PPO

PPO and POS plans allow policyholders to seek out-of-network treatment but at a higher out-of-pocket cost. While a PPO doesn’t require you to choose a PCP or get a referral before seeing a specialist, this requirement will apply to a POS plan. Due to this, PCP plans typically cost more.

POS vs. EPO

A POS plan allows policyholders to seek treatment out-of-network at a higher cost while an EPO plan won’t cover out-of-network care. While an EPO doesn’t require you to get a referral before seeing a specialist, this requirement will apply to POS plans.

FAQs

Is POS a type of insurance?

POS (point-of-service) health insurance is a type of coverage that pays for a member’s medical expenses, both for in-network care and out-of-network care. This plan requires members to elect a primary care physician and obtain a referral before seeing a specialist.

What are the benefits of a POS plan?

A POS plan gives policyholders the ability to receive some coverage for out-of-network care, providing greater flexibility for where to receive medical treatment.

What is the difference between PPO and POS insurance?

PPO plans carry a wider larger medical provider network than POS plans and do not require members to choose a PCP or obtain a referral before seeing a specialist. The PCP and referral for specialists requirement will apply with POS plans.

Key Takeaways

  • POS plans are a type of managed care health insurance that allows policyholders to choose between in-network and out-of-network care, providing a wider range of medical services than other types of managed care plans.
  • Policyholders are typically required to elect a primary care physician and obtain a referral before seeing a specialist.
  • POS plans may have higher out-of-pocket costs for policyholders, especially if they receive care from out-of-network providers, but they offer more flexibility than other types of managed care plans.

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Sources

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